rheumatoid pleuritis · rheumatoid pleuritis by w. c. walker* and v. wrightt fromthe...

Ann. rheum. Dis. (1967), 26, 467

RHEUMATOID PLEURITISBY

W. C. WALKER* AND V. WRIGHTtFrom the Rheumatism Research Unit, University Department of Medicine, General Infirmary, Leeds

Although there was initial reluctance to acceptthe concept, most authorities now believe thatpleural effusion and dry pleurisy may occur assystemic manifestations of rheumatoid arthritis.This belief is based on clinical series in which theincidence of otherwise unexplained pleural effusionhas been unexpectedly high (Horler and Thompson,1959) and on several reports of granulomatouslesions in the pleura considered to be of rheumatoidorigin (Bennett, Zeller, and Bauer, 1940; Gruenwald,1948; Raven, Parkes Weber, and Price, 1948;Ellman, Cudkowicz, and Elwood, 1954; Horlerand Thompson, 1959; Koepke, 1960; Schools andMikkelsen, 1962; Hindle and Yates, 1965; Castle-man and McNeely, 1965). In rheumatoid pneumo-coniosis, the incidence of pleural effusion in thosewith the classical x-ray appearance was 12 5 percent. (Caplan, Payne, and Withey, 1962).

It would be anticipated that controlled investiga-tions should have revealed a greater prevalance ofpleural effusion in rheumatoid subjects than incontrols, but those so far undertaken have yieldedconflicting results. Locke (1963) found a greaterprevalance of pleural effusion in a small selectedseries of rheumatoid subjects than in controls, andTalbot and Calkins (1964) made a similar observa-tion in an autopsy study. By contrast, in largercontrolled investigations, pleural effusion was notfound to be more common (Aronoff, Bywaters, andFearnley, 1955; Stack and Grant, 1965).The uncertainties surrounding pleural effusions

attributed to rheumatoid disease are doubtlesslargely due to the difficulty in establishing a positivediagnosis and in most of the cases so far recordedthis has been reached mainly by exclusion. How-ever, Carr and Mayne (1962) have emphasized thevery low glucose levels in the pleural fluids. Rheuma-toid tissue has been recovered by pleural biopsy

*Consultant Physician, Wakefield Hospitals.tSenior Lecturer in Medicine, Consultant Physician in Rheumatology

(Heller, Kellow, and Chomet, 1956; Schools andDavey, 1960), but as a diagnostic measure this hasbeen disappointing in the experience of others(Ward, 1961; Carr and Mayne, 1962; Mattingly,1964; Poppius and Tani, 1964).Despite the widely held view that attacks of dry

pleurisy are more frequent in rheumatoid subjects,there is no statistical support for this in the onecomprehensive controlled investigation (Short,Bauer, and Reynolds, 1957).

Several authors have reported a high incidence ofpleural adhesions at autopsy (Baggenstoss andRosenberg, 1943; Fingerman and Andrus, 1943;Aronoff and others, 1955; Sinclair and Cruick-shank, 1956; Cruickshank, 1957; Talbot andCalkins, 1964). However, the histological changeshave been non-specific (Sinclair and Cruickshank,1956) and the relationship to the rheumatoid processuncertain.

Clearly several doubts remain regarding rheumatoidpleural lesions. The study here reported formedpart of a comprehensive controlled investigationinto the pleural and pulmonary manifestations ofrheumatoid arthritis which has been recorded indetail elsewhere (Walker, 1966).

Materials and Methods516 patients with definite or classical rheumatoid

arthritis (Ropes, Bennett, Cobb, Jacox, and Jessar, 1959)were studied. 189 were new referrals to the RheumatismClinic of the General Infirmary at Leeds and the re-mainder were follow-up cases. The control groupconsisted of 301 patients with degenerative joint disease(DJD). 221 of them new referrals. In each case a fullhistory was taken, a complete clinical examination done,and the arthritis carefully assessed as recorded elsewhere(Walker, 1966). Respiratory symptoms were noted andevaluated and special inquiry was maderegardingpreviousrespiratory diseases, including pneumonia, pleurisy,pulmonary tuberculosis, or other chest illness. Detailsof smoking habits and the occupational history werenoted. All patients had a chest radiograph, which was

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ANNALS OF THE RHEUMATIC DISEASES

read by one of us (W.C.W.) without knowledge of thegroup to which they belonged. Pleural biopsy was

performed under local anaesthesia, using the Abramspunch (Abrams, 1958) when indicated. All rheumatoidpatients had x rays of the hands and feet and those in theDJD group had films of the affected joints. Haemoglo-bin, white cell count, blood sedimentation rate (BSR),and sheep cell agglutination test (SCAT) were done in allpatients, and other investigations when indicated.

ResultsOf the rheumatoid patients 73 per cent. were

female and of the control patients 79 per cent. Theage distribution of the two groups was reasonablycomparable (Fig. 1).

PleurisyThe number of patients giving a history of pleurisy

in the two groups is shown in Table I.

TABLE IEPISODES OF PLEURISY IN RA AND DJD

Percentage frequency in parenthesis

Diagnosis Male Female Total

RA.39 (28) 68 (18) 107 (21)DJD.4 (6) 32 (13) 36 (12)

Pleurisy was more common in the rheumatoidgroup and in the men the difference was significant(t = 10-5; P < 0 01).The distribution of the attacks of pleurisy in

relation to the onset of arthritic symptoms in thetwo groups is shown in Fig. 2 (opposite). Therewas no difference in the incidence of pleurisy occur-

2,

.ti

0-

0

z

ring more than 5 years before the onset of arthritis.Within 5 years of the onset of arthritis, however,although there was no difference between the twogroups in women, attacks of pleurisy were more

common in the men with rheumatoid arthritis.1 per cent. of the men and 0 5 per cent. of the womenwith rheumatoid arthritis gave a history of pleurisysynchronous with the onset of arthritis. Such a

history was not obtained from any patient in theDJD group. After the onset of arthritis, pleurisywas more common in the rheumatoid group in bothsexes, the difference being particularly striking in themen. In the rheumatoid group two men and twowomen had an exacerbation of arthritis coincidentwith an attack of pleurisy, whereas this did not occur

in the DJD group.

Pleural Effusion

Nineteen patients in the rheumatoid group had a

pleural effusion either at the time of examination or

during the course of their arthritis. Of these, twowere due to other disease processes, but in theremainder careful investigation and observation didnot reveal any evidence of an alternative cause andthey were accepted as cases of rheumatoid pleuraleffusion, an incidence of 3 3 per cent. (in the men

7 * 9 per cent and in the women 1 6 per cent.).The average age at onset of the effusions was 52years in the men and 59 years in the women. In thecontrol group there were two patients with pleuraleffusion and in one of them there was no convincingevidence of any of the usual causes. The differencein the incidence of unexplained pleural effusion in

Rheumatoid arthritis

Males 183

IbO Females 53

120 9 2

80-

40-393

0

-

Degenerative joint disease 95

40 29

29 39 49 59 69 +

Age (yrs. )

Fig. I.-Age distribution of patients with rheumatoid arthritis and degenerative jointdisease.

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RHEUMATOID PLEURITIS

: Rheumatoid arthritisDegenerative joint disease

,, 12

> 5yrs. before < Syrs. before

05 0

synch ron. after

Fig. 2.-Onset of pleurisy related to onset of rheumatoid arthritis and degenerative jointdisease.

the rheumatoid group compared with the controlgroup was statistically significant (x2= 6-1; P <0 02).

Thirty-six per cent. of the men with effusions hadchronic bronchitis compared with 22 per cent. of thetotal male rheumatoid population, but this was not asignificant difference. Other rheumatoid lesionswere known to be present in four cases. One hadinterstitial lung disease, one Caplan's syndrome, andtwo others non-pneumoconiotic intra-pulmonaryrheumatoid nodules, proven histologically. Noother respiratory diseases were more frequent inthose with pleural effusion.

There was no significant difference in the age atonset, the extent of the arthritis, or the functionalgrade in those with and without pleural effusion.The duration of arthritis in those with effusions wasslightly longer than in the group as a whole. Sub-cutaneous nodules were present in eight men andtwo women in the pleural effusion group, 73 percent. and 33 per cent. respectively. In the rheuma-toid population, 44 per cent. of men and 25 per cent.of women had subcutaneous nodules. None of thewomen in the pleural effusion group had any othersystemic manifestations of rheumatoid disease. Ofthe eleven men, one had splenomegaly comparedwith five of the remaining men in the rheumatoidpopulation, one had a myopathy compared withthree other proven cases, three had pericarditis, oneof them a year after the effusion, and no otherexample of pericarditis was encountered amongstmen in the whole series.There was no difference in the haemoglobin levels

of the men with effusions compared with the malerheumatoid population. In the women a haemo-globin level of less than 12 6 g./100 ml. was present

in 67 per cent. (4 of 6) of the effusion group com-pared with 44 per cent. of the rheumatoid group.There was no difference in the BSR.Comparing the results of the SCAT in the pleural

effusion group with the rheumatoid population as awhole, no significant difference was apparent.Three patients with pleural effusion had L.E.-cellsin the peripheral blood, but there was no otherevidence of systemic lupus erythematosus.A low serum albumin was more common (9 of

14, 64 per cent.) in the effusion group than in thetotal rheumatoid population (41 of 212, 19 per cent.)This was a significant difference (x2 = 15 1;P = < 0-01). The serum globulin levels weresimilar in the two groups.There was no difference in the severity of the

radiographic changes in the hands and feet betweenthe two groups.Of those with pleural effusion, 24 per cent. were

non-smokers compared with 45 per cent. of the totalrheumatoid population. Men who smoked morethan ten cigarettes daily for more than 20 years wereequally common in the pleural effusion group andthe total male rheumatoid population (Table II).

TABLE II

SMOKING HABITS AND PLEURAL EFFUSION

No. of Cigarettes Daily(per cent.)

Group11-20 >20

Pleural with Effusion.36 18Total RA .. .. .. .. 33 14

Only one in the effusion group had been exposedto noxious dusts (a furnace cleaner in an iron

MALES

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foundry), compared with 10 per cent. of the totalrheumatoid population.

Temporal RelationsThe relationship between the time of development

of the effusion and the onset of the arthritis innineteen patients (seventeen from the series, twospecially referred) is shown in Table III. The effu-sion came first in one man, preceding the arthritisby a period of at least 6 weeks. In four (18 per

cent.), the effusion occurred synchronously with thearthritis. The onset was regarded as synchronousif either occurred within 4 weeks of the other. Inhalf of the cases the effusion either preceded or

developed within 5 years of the arthritis. Theremainder occurred after varying intervals and some

developed in very long-standing cases. In four theeffusion was accompanied by an exacerbation ofarthritis and in one it occurred very shortly after theappearance of subcutaneous nodules.

TABLE IIIONSET OF EFFUSIONS RELATED TO ONSET OF RA-22

EPISODES IN 19 PATIENTS

Years afterSex Before Synchronous

>5 6-10 11-20 >20

Male .. 1 2 5 2 4 2Female.. 0 2 1 1 1 1

Total .. 1 4 6 3 5 3

In one man and one woman there were no

symptoms attributable to the pleural effusions, bothbeing detected by routine chest radiography. Eitherunilateral or bilateral pleuritic pain occurred in tenmen and five women. Dyspnoea of varying severityoccurred in seven men and three women, three menand three women had cough, and in one man andone woman fever was known to occur. Themajority of cases, therefore, had symptoms, pleuriticpain being the commonest.

Characteristics of EffusionThe effusion was bilateral in four, on the left side

in six, and on the right side in twelve. The size ofthe effusions varied from small collections, producinglittle more than obliteration of the costophrenicangle, to a radiographic opacity involving about halfof the hemi-thorax. In most cases there was amoderate amount of fluid involving between onethird and one half of the hemi-thorax.

*The fluid on aspiration was serious in all but onecase with a purulent effusion.

Differential cell counts, done on the pleural fluidin thirteen cases, were predominantly lymphocytic insix, polymorphs predominated in three and in the

remaining four there was a mixed- cell population.The glucose levels in twelve specimens of pleural

fluid from eight patients are shown in Table IV.TABLE IV

GLUCOSE LEVELS IN PLEURAL FLUID IN EIGHT PATIENTS

Patient No. mg./100 ml.

1 112, 122, 1052 03 654 165 80, 856 1207 608 40, 60

In one case no glucose was present and in anotherthe level was very low at only 16 mg./100 ml. In athird the initial level was 40 mg./100 ml. but 2imonths later the level had increased to 60 mg./100ml. In the remainder the initial level was 60 mg.or more. In one case the level was followed seriallyover a period of 10 months; it was above 100 mg./100 ml. on each occasion.

Protein levels in the pleural fluid were estimatedin seven cases; they varied from 3 *7 to 5 *5 g./100 ml.,figures merely indicating that the effusion was anexudate.

In eight patients the SCAT was carried out onboth the blood and the pleural fluid (Table V).

TABLE VSCAT TITRES IN PLEURAL FLUID AND BLOOD IN EIGHT

PATIENTS

Patient No. Pleural Fluid Blood

1 512, 512, 256 1282 negative negative3 256 2564 1024 2565 negative negative9 512 326 512 5127 negative negative

In three cases the SCAT was negative in both.In three of the remaining five cases there was morethan a one-tube difference in the titres, that in thepleural fluid being higher than in the blood.

Pleural PathologyPunch biopsy of the parietal pleura was performed

in eleven cases considered to have a rheumatoidpleural effusion and in one with pleural thickening.The pathological changes found will be reportedseparately. In four cases the biopsy was regardedas giving positive help in diagnosis.

TreatmentIn two of the nineteen cases, oral corticosteroid

therapy was given specifically because of the pleural

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effusion, and in both resolution occurred shortlyafterwards. In one case intra-pleural corticosteroidtherapy was given without any obvious benefit.Single or repeated aspirations were employed fortreatment purposes in nine cases.

Natural History

In thirteen the effusion resolved within 3 months,but in one of these there was a recurrence 12 monthslater. In four the effusion was unduly persistent.In one the duration has been over 2 years so far,with only temporary improvement after aspiration.In a second the effusion persisted for 18 monthsbefore finally resolving. In one man the effusionpersisted for 15 months and during this time hedeveloped severe pleural thickening, which resultedin gross restriction of respiratory movement on thatside and associated dyspnoea. Decortication hadto be performed, which relieved his symptoms. Afourth patient, a man with empyema, had persistentpleural fluid for 5 years, until he died as a result ofrenal papillary necrosis.

Three more of the nineteen patients died, the firstas a result of cardiac tamponade from pericardialeffusion, the second from lobar pneumonia on theopposite side to that of the effusion, and the thirdfrom amyloidosis.

Discussion

This investigation has demonstrated a significantlyhigher incidence of pleural effusion in the rheuma-toid population than in the control group, a result atvariance with the findings of Aronoff and others(1955) and Stack and Grant (1965). HoweverAronoff and others (1955) x-rayed their patients onlywhen clinically indicated and used as a control group

patients referred to hospital for chest radiography.Stack and Grant (1965) reviewed the chest radio-graphs of rheumatoid patients taken at their firstattendance at a rheumatic clinic and therefore wouldonly detect cases who had a pleural effusion at thattime. In the present study account has been takenof pleural effusion occurring at any time during thenatural history of the rheumatoid process and cases

covering a wide spectrum have been included in thereview. Moreover, in none of the previous con-

trolled investigations has a comparison been madewith patients in whom there is no known associationwith respiratory disease.Although all those with pleural effusions were

carefully investigated for an alternative cause, thisdoes not prove that the effusions were due to therheumatoid process. It has been suggested that

tuberculosis (Miall, 1955), pyogenic infections(Lewis-Faning, 1950), and pulmonary embolism(Cobb, Anderson, and Bauer, 1953) are morecommon in rheumatoid subjects, and such factorsrequire consideration. In this series, evidence oftuberculous infection was not more frequent in therheumatoid than in the control group; a history ofpneumonia was more common but most of theattacks occurred before the onset of arthritis(Walker, 1967); venous thrombosis was also morecommon but there was a striking predominance offemales affected (9:1) in contrast to the male pre-dominance in pleural effusion. There is thereforeno evidence to suggest that any of these conditionsaccounted for the greater prevalence of pleuraleffusion, but on the other hand such observations donot establish that they were rheumatoid in nature.However, it is difficult to reach an alternativeconclusion when consideration is given to the avail-able evidence. Firstly, this series has demonstratedan excess of otherwise unexplained pleural effusionsin rheumatoid subjects compared with a controlgroup, whereas the incidence of "explained" pleuraleffusions was virtually identical in the two groups(0* 4 and 0 - 3 per cent. respectively). Secondly,rheumatoid granulation tissue in the pleura has beenreported by several authors, and in all but one ofthe cases described pleural effusion has been present.Thirdly, careful study did not reveal an alternativeexplanation. More patients in the effusion grouphad L.E.-cells in the peripheral blood, but there wasno other evidence of systemic lupus erythematosusand they were considered to be examples of rheuma-toid arthritis with L.E.-cells.

One of the objects of this investigation was toevaluate criteria for diagnosis in the examination ofrheumatoid pleural effusion. The differential cellcount was not helpful. Carr and Mayne (1962)emphasized the very low glucose level in the pleuralfluid, but in the present series a level of 40 mg. or lesswas found in only three of the eight patients in whomthe investigation was done. Moreover, in three otherpatients with levels of 65 mg./100 ml. or more,subsequent histological examination of the pleuraundertaken either at autopsy or after decorticatiordid not reveal evidence of an alternative pathologicalprocess. There was no correlation between lowpleural glucose levels and the histological findingsin the pleura at biopsy, and serial readings in threepatients did not suggest that they were dependenton the duration of the effusion. The glucose levelsin this series were not examined in the fasting state,since the figures of Carr and Mayne (1962) did notindicate that this influenced the results in those withvery low levels.

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Rodnan, Eisenbeis, and Creighton (1962) showedthat occasionally tests for rheumatoid factor werepositive in joint fluid and negative in the blood.The titre of rheumatoid factor in the pleural effusionand serum was therefore compared in eight patients.In three with a positive SCAT in the blood, a highertitre was present in the pleural fluid. It is possiblethat such a finding might be of diagnostic value butmore cases require to be studied, including a groupof rheumatoid patients with effusion due to othercauses.

The findings on pleural biopsy will be discussedelsewhere. This technique yielded information ofpositive value more frequently in this series thanhasbeen suggested by previous investigators. How-ever in over half the cases only non-specific changeswere present.

These studies indicate that investigation of thepleural fluid and pleural biopsy does not permit apositive diagnosis of rheumatoid pleural effusion inmore than a proportion of cases. A very lowpleural glucose level is certainly helpful but normallevels are found in some cases.

In many cases, therefore, the diagnosis will largelydepend on exclusion of other causes and on sugges-tive clinical features such as the pleural effusionaccompanying the onset of the arthritis or occurringwith an exacerbation of arthritis. About one-fifthare bilateral and in a similar proportion intra-pulmonary rheumatoid lesions are present.

In this series resolution of the effusions occurredwithin 3 months in thirteen of the nineteen casescompared with seven of thirteen described by Carrand Mayne (1962). The effusions were undulypersistent in four patients. Hitherto, little stresshas been laid on possible complications of rheuma-toid effusions, apart from residual pleural thickeningwhich has usually been minimal. However, in twocases, major pleural complications ensued and thesewere the only examples in the series in which lesionsregarded as intra-pulmonary rheumatoid noduleswere present. In one case pleural thickening was soextensive that decortication was required to relievedyspnoea. In the second there was an empyemawhich persisted for 5 years until his death and therewere good grounds at autopsy for believing that theinitial pleural pathology had been rheumatoid innature. This case is reminiscent of that describedby Cudkowicz, Madoff, and Abelmann (1961).The pleural space may well have become infected forreasons similar to those accounting for pyarthrosisin rheumatoid arthritis (Kellgren, Ball, Fairbrother,

and Barnes, 1958) and distinct from the pyopneu-mothorax which may result from rupture of sub-pleural rheumatoid nodules (Hindle and Yates,1965; Davies, 1966).

The one patient who received intra-pleuralcorticosteroids did not benefit. In the two patientswho received oral corticosteroids the pleural effu-sions resolved quite rapidly, but it is uncertainwhether this was the result of treatment.

The reason for the striking male predominance inthis and previously-reported series remains obscure.It is of interest that more men with pleural effusionin this series had chronic bronchitis than in therheumatoid population as a whole, and noteworthythat effusions occurred in as many as 12 * 5 per cent.of those with the classical x-ray appearance ofCaplan's syndrome (Caplan and others, 1962).These observations raise the possibility that environ-mental factors may play a part, but if this is so it issurprising that there was no correlation betweenprolonged smoking and pleural effusion in thisseries.

In keeping with the findings of others, the effusiontended to develop in the sixth decade. As might beanticipated, subcutaneous nodules were morecommon in those with pleural effusion than in therheumatoid population, particularly in men. Inaddition, the only three examples of pericarditis inmen encountered in the whole series occurred inpatients with pleural effusion. This suggests acorrelation between involvement of the pleura andpericardium in rheumatoid arthritis and two recentreports are in keeping with this (Beck and Hoff-brand, 1966; Berger and Seckler, 1966). There was,however, no evidence of a correlation with any othersystemic lesions. The severity of the arthritis asassessed clinically and radiologically did not differin those with pleural effusion when compared withthose without, and the haematological and serolo-gical findings were also similar. A low serumalbumin was more frequent in the patients withpleural effusion than in the rheumatoid population,and analysis revealed that there was a correlationbetween a low serum albumin and the presence ofsubcutaneous nodules.

The greater frequency of a history of pleurisy inmen with rheumatoid arthritis compared with thecontrol group and the temporal relationship to thearthritis was of interest in view of the comparablefindings in those with pleural effusion. Suchretrospective information suggests, although it doesnot establish that dry pleurisy occurs as a systemicmanifestation of rheumatoid arthritis.

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Summary and Conclusions

516 patients with definite or classical rheumatoidarthritis have been studied clinically, radiographic-ally, and serologically in order to evaluate the pleuralmanifestations more fully. 301 patients withdegenerative joint disease were simultaneouslyinvestigated to serve as a control group. Pleurisywas more common in the rheumatoid group,particularly in men. There was strong evidence tosupport the view that pleural effusion may occur as amanifestation of rheumatoid disease. Unexplainedeffusion was significantly more frequent in therheumatoid group, especially in men, and occurredparticularly in cases of nodular rheumatoid arthritis.Intra-pulmonary lesions of rheumatoid origin wereoften present and pericarditis seemed to be anassociated feature in men.Methods for establishing an early definitive

diagnosis of rheumatoid pleuritis were assessed.

Very low glucose levels in the pleural fluid were lessfrequently present than previously suggested, butpleural biopsy was helpful in 42 per cent. In somepatients the sheep cell agglutination titre was higherin the pleural fluid than in the blood. The effusionsusually appeared to be benign, but were undulypersistent in four patients and resulted in majorpleural complications in two. There was noevidence that smoking or exposure to noxious dustswere aetiological in the pleural effusions in thesepatients.Although clearly all cases must be thoroughly

investigated for an alternative aetiology, ourexperience indicates that pleural effusion developingin patients with rheumatoid arthritis seen at arheumatism clinic is most likely to be due to therheumatoid disease.We are grateful to Dr. 0. H. J. Maxwell Telling and

Dr. M. R. Jeffrey for allowing us to study patients undertheir care.

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Ward, R. (1961). Lancet, 2, 1336 (Pleural effusion and rheumatoid disease).

La pleurite rhumatismaleOn etudia 516 cas d'arthrite rhumatismale classique

ou "definie" du point de vue clinique, radiologique ets6rologique pour evaluer d'une maniere plus detaillee lesmanifestations pleurales. En meme temps on etudia 301cas d'affection articulaire degenerative en guise detemoin. L'atteinte pleurale etait plus frequente chez lesmalades atteints d'arthrite rhumatismale, en particulierchez les hommes. 11 y eut de serieux indices permettant depenser que l'epanchement pleural pouvait se produire en

tant que manifestation de la maladie rhumatismale. Un-panchement inexplique fut significativement plusfrequent dans le groupe ayant une arthrite rhumatismale,particulierement chez les hommes, surtout en cas d'arth-rite rhumatismale nodulaire. Des lesion pulmonairesd'origine rhumatismale furent souvent trouvees et une

pericardite sembla etre un caractere associe chez leshommes.On evalua des methodes pour etablir un diagnostic

precoce et certain de pleurite rhumatismale. On trouvamoins souvent qu'on ne le pensait des taux tris bas deglucose dans le liquide pleural, mais dans 42 pour centdes cas la biopsie pleurale fut utile. Chez quelquesmalades le taux de la reaction de Waaler-Rose etait pluseleve dans le liquide pleural que dans le sang. Lesepanchements paraissaient generalement benins, maischez quatre malades ils persisterent assez longtemps etchez deux d'entre eux ils entrain6rent des complicationspleurales majeures. On ne trouva pas d'indices permettantd'impliquer la responsabilite du tabac ou de poussi&resnocives comme etiologie des epanchements pleuraux.

Bien que, naturellement, on doive explorer A fond tousces malades en vue d'une autre etiologie, notre exp6rienceprouve que l'epanchement pleural survenant chez lesmalades ayant une arthrite rhumatismale vus dans un

service de rhumatologie est vraisemblablement du A lamaladie rhumatismale.

La pleuritis reumatoideSe estudiaron 516 casos de artritis reumatoide clasica o

"definida" clinica, radiol6gica y serol6gicamente paravalorar de una manera mas detallada las manifestacionespleurales. Al mismo tiempo se estudiaron 301 casos deafecci6n articular degenerativa, que sirvieron de testigos.La lesi6n pleural fue mas frecuente en enfermos conartritis reumatoide, en particular del sexo masculino.Existieron datos importantes para indicar que el derramepleural puede producirse en funci6n de la enfermedadreumatoide. Un derrame sin explicaci6n fue significativa-mente mAs frecuente en el grupo con artritis reumatoide,especialmente en hombres y particularmente en casos deartritis reumatoide nodular. Se encontraban a menudolesiones pulmonales de origen reumatoide y una peri-carditis parecia ser un rasgo asociado en los hombres.

Se valoraron los metodos para establecer un diagn6s-tico pronto y cierto de pleuritis reumatoide. Muy bajascifras de glucosa en el liquido pleural fueron encontradascon una frecuencia menor que la indicada anteriormente,pero en un 42 por ciento de los casos la biopsia pleuralfue util. En algunos enfermos las cifras de la reacci6n deWaaler-Rose fueron mAs altas en el liquido pleural queen el suero. Los derrames parecieron generalmentebenignos, pero en cuatro enfermos persistieron bastantetiempo y en dos de ellos llevaron a mayores complica-ciones pleurales. No se encontraron indicios implicandoel tabaco o el polvo nocivo en la etiologia de los derramespleurales en estos enfermos.

Es claro que todos estos casos merecen una investi-gaci6n completa en busca de otra etiologia, pero nuestraexperiencia indica que un derrame pleural ocurriendo enun enfermo con artritis reumatoide y visto en un serviciode reumatologia se debe muy probablemente a la enferme-dad reumatoide.

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